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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	3033631		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780306	MR00161301	00	03/03/2021	03/03/2021	03/04/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	45	100.00000	Replenished		1001860456	3056066373
False	3285617		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780775	MR00161301	01	04/09/2021	04/09/2021	04/10/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	45	100.00000	Replenished		1001860456	3056066373
False	3577397		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780775	MR00161301	02	05/17/2021	05/17/2021	05/18/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	10	22.22200	Replenished		1001860456	3056066373
False	3580460		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780775	MR00161301	02	05/17/2021	05/17/2021	05/18/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	35	77.77800	Replenished		1001879330	3059650533
False	3688146		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782387	MR00161301	00	06/03/2021	06/03/2021	06/04/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	45	100.00000	Replenished		1001879330	3059650533
False	3823516		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782843	MR00161301	00	06/23/2021	06/23/2021	06/24/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	20	44.44400	Replenished		1001879330	3059650533
False	3834886		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782843	MR00161301	00	06/23/2021	06/23/2021	06/24/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	25	55.55600	Replenished		1001899045	3063437222
False	4057637		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783349	MR00161301	00	07/15/2021	07/15/2021	07/16/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	45	100.00000	Replenished		1001899045	3063437222
False	4187530		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783719	MR00161301	00	08/02/2021	08/02/2021	08/03/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	15	33.33300	Replenished		1001915815	3066004377
False	4184257		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783719	MR00161301	00	08/02/2021	08/02/2021	08/03/2021	00093220401	METOCLOPRAMIDE 5 MG TABLET	5 MG	TABLET	100	45	30	66.66700	Replenished		1001899045	3063437222